GW1-2022-06927_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATERZONFS
Well Contractor Name FROM TO DESCRIPTION
4449-A 245 ft. 305 fL waw f
ft. ft.
NC Well Contractor Certification Number 15.OUTER'CASiNG fer'mnlB eased wd13 OR LINER a eabte
Rowan Well Drilling FROM To DIAMETER THICKNFSs MATERIAL``
0 ft 115 ft. 6114' m. SDR 21 PVC
Company Name ,16i ffWR CASING OR TlJB1NG'. thermfl'dosed-loo
2.Well Construction Permit#: 13661 FROM I To DIAMETER 1Hlcr NEss MATERIAL
List all applteable well construction permits(i e.WC,County,State,Variance,etc.) & ft. in.
3.Well Use(check well use): & fL is
Water Supply Well: 17 St REEK
FROM TO DIAMETER SLOT SIZE THIC NFSS MATERIAL
Agricultural 13Municipal/Public ft. %
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) & ft
Industrial/Commercial Residential Water Supply(shared) 18'GROITr ."
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUN7
Non-Water Supply Well: o ft- 20 ft. Haeprug orevity 13bags
Monitoring .Recovery ft. ft.
Injection Well: fL
Aquifer Recharge QGroundwater Remediation 19.'SAND/GRAKEL PACK a litabk
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
_ Aquifer Test JoStormwater Drainage ft. fL
Experimental Technology 13Subsidence Control ft. it.
Geothermal(Closed Loop) QTracer ^.30:DRILLING LOG auacksidditionshsheeta if nteessii'
Geothermal eatin FROM TO DESCRiMON Coolin Return Other lain under#21 Remarks color soahoek etc.
0 ft• 15 fL Clayt'Sand
4.Date Wells)Completed:5127/22 Well ID#13651 1s ft- 40 ft. Sandy overburden
Sa.Well Location: Q fL 105 & Wbattwad Roar
Cornerstone III Properties 105 ft. 115 ft. SaW Rock
Facility/Owner Name Facility Ill#(ifopplicabie) ft. ft.
250 St Marks Ch Rd, Cherryville 28021 fL ft.
Physical Address,City,and Zap ft' ft.
Gaston 3509 01 0959 21xEMARIcs".
County Parcel Identification No.(PIN) r.rt
5b.Latitude and longitude in d i'�3;4A'il,'r`��PP,0CCSe1 v G Ji\I
ng+i egrees/minutes/secoads or decimal
(if well field,one fat/long is sufficient) 22.Certification:
35 21 2A99 N 81 20 56.545
� Z-7 6,
6.Is(are)the well(s)OPermanent or Temporary Signature o Certified well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or EINo with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
#'this is a repair,fill out known well construction information and explain the not=of the copy ofthis retord has been provided to the well owner.
repair under#21 remarks section or on the bade of ibis form.
23.Site diagram or additional well details:
8.For GeoprobeMPT or Closed-Loop Geothermal Welb having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (fl.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths tfdtfjeremt(example-3Q200'and 2@1005 construction to the following:
10.Static water level below top of casing: UP Division of Water Resources,Information Processing Unit,
if waterlevel is above castng;use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b,For Iniectioa Wells: In addition to sending the form to the address in 24a
above,also submit one copy of�this form within 30 days of completion of well
12.Well construction method: Rota construction to the following: f
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) i0 Method of test: aid,k 24c.For Water Suonhr&Jul lion Wills: in addition to sending the form to
the address(es) above, also subinit one copy of this form within 30 days of
13b.Disinfection type: chlorine Amount- t4 oZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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